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One of the toughest obstacles
to implementation of a computer-based medical records system is
how to capture the provider’s dictation.
Typing (by the physician or the transcriptionist), voice
dictation, or scanning in a hand-written note, all slow down the
physician, and introduce costly, unnecessary steps.
The most efficient method,
by far, is via the use of Templates. Templates are
lists of commonly-used Text Phrases that
a provider “clicks” (with the mouse), one-at-a-time, to build his or her
dictation. For example, given
the list of Text Phrases below:
- The
patient is here for follow-up of
- type
one diabetes mellitus
- type
two diabetes mellitus
- dyslipidemia
- hypertension
- elevated
body mass index
- osteoarthritis
involving multiple joints
- ophthalmic
or visual problems
- kidney
disease
- complicated
by
- and
The physician might click on
lines 1, 3, 10, 4, 5, 11, and 9, to build the following dictation:
The
patient is here for follow-up of type two diabetes
mellitus complicated by dyslipidemia, hypertension,
and kidney disease.
The optimal goal of Templates is
to have one thought or concept tied to one mouse click. Each mouse
click should lead to a new set of choices that logically follow the previous
choice. Templates designed
in this way allow the provider to enter his or her dictation as fast as he/she
can think. It is possible to do this and we have many providers
on the Team
Chart Concept who do just that. The "catch" is
that you, the provider, must spend time up-front designing and writing your Templates. If
this time is taken, the realized time-savings can be substantial. Why
continue to say the same things over and over, when you can enter them into
the Team Chart
Concept as Templates one
time?
Of course, clicking on one Text Phrase can not only insert text into the dictation, it can also
branch to a whole new set of choices. Here
are typical branches:
- Go
Chief Complaint
- Go
Review Of Systems
- Go
Physical Exam
- Go
Data Review
- Go
Management
Clicking on a Text
Phrase can also insert a complete sentence or paragraph. For example:
- [Eyes
– Normal]
- [Ears
– Normal]
- [Sinus -
Normal]
If the Text
Phrase [Eyes
– Normal] is clicked, the following might be entered into the
dictation:
Eyes : The
pupils are equal and reactive to light and accommodation. The
extraocular motions are normal.
Medicare
Audit Points can be assigned to
each Text Phrase. Once
all Text Phrases are clicked into the dictation, an audit point total
verifies that documentation exists for the level of care selected.
Because the Team
Chart Concept is a complete system for the medical office,
requests for employees, (called To Do Requests) can be assigned to specific Text Phrases. When those Text
Phrases are clicked into dictation, To
Do Requests are automatically generated. Given
the Template choices:
- The
patient will return for review of
- urinalysis
- CBC
- fasting
glucose
- glycosolated
hemoglobin
- lipid
profile
- chest
x-ray
- ,
- and
The
provider can build the following dictation (in 7 mouse clicks)
The patient will return for review of CBC,
lipid profile, and urinalysis.
AND automatically send To
Do Requests to the office staff to make a follow-up appointment, perform
blood work, and request lab tests.
Physicians can build their own Templates.
Once familiar with his or her Templates,
the physician can enter audited dictation, AND make requests of
the staff, as fast as he or she can literally think.
With the Team
Chart Concept, this can easily be done in real-time,
on-time, with the patient in the exam room.
When the physician leaves the exam room, documentation is
complete, prescriptions have been printed, orders have been given,
charges/diagnoses have been selected, and insurance can be billed.
Next patient please.
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Provider
Dictation
